ABSTRACT
BACKGROUND: Chronic obstructive pulmonary disease (COPD) generates a high burden on health care, and hospital admissions represent a substantial proportion of the overall costs of the disease. Integrated care (IC) has shown efficacy to reduce hospitalisations in COPD patients at a pilot level. Deployment strategies for IC services require assessment of effectiveness at the health care system level. AIMS: The aim of this study was to explore the effectiveness of a community-based IC service in preventing hospitalisations and emergency department (ED) visits in stable frail COPD patients. METHODS: From April to December 2005, 155 frail community-dwelling COPD patients were randomly allocated either to IC (n=76, age 73 (8) years, forced expiratory volume during the first second, FEV1 41(19) % predicted) or usual care (n=84, age 75(9) years, FEV1 44 (20) % predicted) and followed up for 12 months. The IC intervention consisted of the following: (a) patient's empowerment for self-management; (b) an individualised care plan; (c) access to a call centre; and (d) coordination between the levels of care. Thereafter, hospital admissions, ED visits and mortality were monitored for 6 years. RESULTS: IC enhanced self-management (P=0.02), reduced anxiety-depression (P=0.001) and improved health-related quality of life (P=0.02). IC reduced both ED visits (P=0.02) and mortality (P=0.03) but not hospital admission. No differences between the two groups were seen after 6 years. CONCLUSION: The intervention improved clinical outcomes including survival and decreased the ED visits, but it did not reduce hospital admissions. The study facilitated the identification of two key requirements for adoption of IC services in the community: appropriate risk stratification of patients, and preparation of the community-based work force.
Subject(s)
Patient Care Team/organization & administration , Aged , Aged, 80 and over , Disease Progression , Emergency Service, Hospital/statistics & numerical data , Female , Frail Elderly , Hospitalization/statistics & numerical data , Humans , Intention to Treat Analysis , Male , Pulmonary Disease, Chronic Obstructive/mortality , Quality of Health Care , Risk AssessmentABSTRACT
BACKGROUND: Ambulance professionals often address conflicts between ethical values. As individuals' values represent basic convictions of what is right or good and motivate behaviour, research is needed to understand their value profiles. OBJECTIVES: To translate and adapt the Managerial Values Profile to Spanish and Swedish, and measure the presence of utilitarianism, moral rights and/or social justice in ambulance professionals' value profiles in Spain and Sweden. METHODS: The instrument was translated and culturally adapted. A content validity index was calculated. Pilot tests were carried out with 46 participants. ETHICAL CONSIDERATIONS: This study conforms to the ethical principles for research involving human subjects and adheres to national laws and regulations concerning informed consent and confidentiality. FINDINGS: Spanish professionals favoured justice and Swedish professionals' rights in their ambulance organizations. Both countries favoured utilitarianism least. Gender differences across countries showed that males favoured rights. Spanish female professionals favoured justice most strongly of all. DISCUSSION: Swedes favour rights while Spaniards favour justice. Both contexts scored low on utilitarianism focusing on total population effect, preferring the opposite, individualized approach of the rights and justice perspectives. Organizational investment in a utilitarian perspective might jeopardize ambulance professionals' moral right to make individual assessments based on the needs of the patient at hand. Utilitarianism and a caring ethos appear as stark opposites. However, a caring ethos in its turn might well involve unreasonable demands on the individual carer's professional role. Since both the justice and rights perspectives portrayed in the survey mainly concern relationship to the organization and peers within the organization, this relationship might at worst be given priority over the equal treatment and moral rights of the patient. CONCLUSION: A balanced view on ethical perspectives is needed to make professionals observant and ready to act optimally - especially if these perspectives are used in patient care. Research is needed to clarify how justice and rights are prioritized by ambulance services and whether or not these organization-related values are also implemented in patient care.
Subject(s)
Ambulances , Conflict, Psychological , Emergency Medical Services/ethics , Emergency Medical Technicians/psychology , Adult , Emergency Medical Technicians/statistics & numerical data , Ethical Theory , Female , Humans , Male , Middle Aged , Patient Rights/ethics , Pilot Projects , Social Justice/ethics , Spain , Surveys and Questionnaires , Sweden , TranslatingABSTRACT
Objetivo: Este artículo tiene como objetivo analizar las representacionesque una serie de mujeres embarazadas expusieron sobre el cuerpo,revisando las influencias externas sobre sus experiencias.Diseño: Metodología cualitativa con un enfoque antropológico.Resultados: Las interpretaciones y experiencias del cuerpo fueron diversasy evolucionaron a lo largo del embarazo. Entre ellas destacamossu percepción positiva, al responder de forma natural y automática,aunque conllevara a su transformación-deformación. La previsión delaumento de peso fue una imagen preocupante para la mayoría y, aunqueaceptada, se tradujo en prácticas de autocontrol. Otras experienciasfueron de ocupación e interpretación del cuerpo a partir de los discursosprofesionales.Conclusiones: Conocer las representaciones que las mujeres hacen desus cuerpos en gestación y revisar las propias puede mejorar la efectividadde los cuidados (AU)
Objetive: The purpose of this paper is to analyze the representations ofthe body presented by pregnant women, through the review of their influenceon their experiences.Design: Qualitative methodology with a anthropologic design.Results: Their corporal perceptions and experiences were very diverseand developed throughout the pregnancy. Among them, we highlighttheir positive perception, due to the natural and automatic response,although it leads to its transformation-deformation. The predictableweight gain was a worrying image for most of them. The prediction ofweight gain was an image of concern for most of them, and, althoughthey accepted it, it leads to self-control practices. Other experienceswere of feelings of invasion and interpretation of their body followinginteractions with professionals.Conclusions: Knowing womens representations of their pregnant bodiesand revising our own may improve the effectiveness of prenatal care (AU)
